1

Clinical Policy Title: Electrical muscle stimulation

Clinical Policy Number: CCP.1377

Effective Date: June 1, 2018

Initial Review Date: April 10, 2018

Most Recent Review Date: May 7, 2019

Next Review Date: May 2020

Related policies:

CCP.1009 Pulmonary rehabilitation

CCP.1020 Botulinum toxin products

CCP.1041 Phrenic (diaphragmatic) nerve stimulation

CCP.1197 Transcutaneous electrical nerve stimulators

ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas’

clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state

regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional

literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements,

including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by

AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or

federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control.

AmeriHealth Caritas’ clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians

and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas’ clinical policies are

reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as

necessary. AmeriHealth Caritas’ clinical policies are not guarantees of payment.

Coverage policy

AmeriHealth Caritas considers the use of electrical muscle stimulation (also referred to as

neuromuscular electrical stimulation) to be clinically proven and, therefore, medically necessary when

used in accordance with U.S. Food and Drug Administration labeling instructions for each device for the

following indications:

To correct lack of ankle dorsiflexion (foot drop) of central neurological origin when an ankle-

foot orthosis is not tolerated (Healthcare Common Procedure Coding System code E0770)

(Moll, 2017; National Institute for Health and Care Excellence, 2009; Prenton, 2018).

To attenuate muscle disuse atrophy in immobilized lower limbs (Healthcare Common

Procedure Coding System code E0745) following a non-neurological injury or surgery where

Policy contains:

Functional electrical stimulation.

Neuromuscular electrical

stimulation.

Physical rehabilitation.

2

the nerve supply to the muscle is intact (e.g., post orthopedic surgery, casting, splinting, or

soft-tissue scarring) (Bistolfi, 2018; Hauger, 2018; Wylde, 2018).

To correct or prevent glenohumeral subluxation following an acute or subacute stroke (Lee,

2017; Winstein, 2016).

To restore upper limb function (Healthcare Common Procedure Coding System code E0770)

following an acute or subacute stroke or spinal cord injury in the presence of minimal

volitional movement, when combined with task-specific training (e.g., grasp function), after

a trial showing evidence of muscle contraction but an inability to move the arm against

resistance (de Freitas, 2018; Fehlings, 2017; Mirkowski, 2019; Monte-Silva, 2019; National

Institute for Health and Care Excellence, 2013).

To enable independent, unbraced ambulation using the Parastep 1® system (Sigmedics Inc.,

Fairborn, Ohio) (Healthcare Common Procedure Coding System code E0764) for skeletally

mature members with spinal cord injury, who meet all of the following criteria (Sigmedics,

2019)

- Intact lower motor units (both muscle and peripheral nerve of L1 and below).

- Muscle and joint stability of the upper and lower extremities for weight bearing,

with demonstration of balance and trunk control to independently maintain an

upright posture.

- Demonstration of brisk muscle contraction to neuromuscular stimulation and have

sensory perception of electrical stimulation sufficient for muscle contraction.

- Ability to transfer independently and demonstrate independent standing tolerance

for at least three minutes.

- Possession of high motivation, commitment, and cognitive ability to use the device

for walking.

- Demonstration of hand and finger function to manipulate the device controls.

- At least six-month post-recovery from spinal cord injury and restorative surgery.

- Absence of degenerative disease of the hip and knee, and no history of long bone

fracture secondary to osteoporosis.

- Demonstration of a willingness to use the device for a long term.

AmeriHealth Caritas considers the use of a U.S. Food and Drug Administration-approved conductive

garment (Healthcare Common Procedure Coding System code E0731) in conjunction with

neuromuscular electrical stimulation to be medically necessary for members with a medical need for

rehabilitation strengthening (pursuant to a written plan of rehabilitation), where the nerve supply to the

muscle is intact, for any of the following indications:

There is a large area or many sites to be stimulated, and the stimulation would have to be

delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes,

and lead wires.

There is a medical condition (e.g., skin condition) that precludes the application of

conventional electrodes, adhesive tapes, and lead wires.

3

Area to be treated for disuse atrophy or chronic intractable pain is inaccessible to

conventional electrodes, adhesive tapes, and lead wires (e.g., underneath a cast).

Limitations:

All other uses of electrical muscle stimulation are not medically necessary, as the safety and

effectiveness has not been established. These include, but are not limited to:

Muscle disuse atrophy in members with spinal cord injury.

Pain control.

Non-medical uses (e.g., exercise).

Oropharyngeal dysphagia (Bath, 2018).

Absolute contraindications to electrical muscle stimulation include (Sigmedics, 2019):

Autonomic dysreflexia.

Cardiac pacemakers.

Presence of irreversible contracture.

Presence of skin disease or cancer at the area of stimulation.

Severe osteoporosis.

Severe scoliosis.

Requirements for functional electrical stimulation of the upper or lower extremities include attended

physical therapy training with the device. The physical therapist performing this training must have

sufficient skills to provide these services that are part of a one-on-one training program in inpatient

hospitals, outpatient hospitals, comprehensive outpatient rehabilitation facilities, and outpatient

rehabilitation facilities.

A conductive garment used with neuromuscular electrical stimulation (Healthcare Common Procedure

Coding System code E0731) is not medically necessary when the service can be delivered effectively

through the use of conventional electrodes, adhesive tapes, and lead wires.

The use of the Hako-Med PRO ElecDT® 2000 (Hako Med Holdings Inc., Las Vegas, Nevada, distributed in

the United States by Alive Inc.) for electrical muscle stimulation is not medically necessary, as its safety

and effectiveness has not been established.

Replacement supplies are considered medically necessary when used with medically necessary

neuromuscular electrical stimulation up to plan limits.

For Medicare members only:

AmeriHealth Caritas considers electrical muscle stimulation to be reasonable and necessary in

accordance with Medicare National Coverage Determinations 160.12 and 160.13 and Decision Memo

4

for Neuromuscular Electrical Stimulation for Spinal Cord Injury (CAG-00153R). The approved indications

are:

To treat disuse atrophy where nerve supply to the muscle is intact, including brain, spinal

cord, and peripheral nerves, and other non-neurological reasons for disuse atrophy.

Treatment involves stimulating the muscle when the patient is in a resting state.

To enhance the ability to walk in members with spinal cord injury.

All other uses are not medically necessary.

For members with spinal cord injury, coverage is limited to enhancing ambulation and completing a

training program, which consists of at least 32 physical therapy sessions with the device over three

months. The trial period of physical therapy will enable the physician treating the member for spinal

cord injury to properly evaluate the member’s ability to use these devices frequently and for the long

term. Physical therapy necessary to perform this training must be directly performed by the physical

therapist as part of a one-on-one training program. The only settings where therapists with sufficient

skills to provide these services are employed in inpatient hospitals, outpatient hospitals, comprehensive

outpatient rehabilitation facilities, and outpatient rehabilitation facilities.

Alternative covered services:

Occupational therapy.

Physical therapy.

Speech therapy.

Specialist consultation.

Hip-knee-ankle-foot orthoses.

Background

Electrical stimulation is one of many interventions employed to restore body movement critical for daily

function and quality of life. Available in many forms, electrical stimulation facilitates changes in either

bioelectrical or biochemical communication among cellular components to effect muscle action, pain

modulation, and performance. Electrodes may be positioned transcutaneously, percutaneously, or

subcutaneously. Small portable units with modifiable capabilities are the most popular, because they

allow providers to set parameters and design custom programs that patients can use in the clinic or at

home (Doucet, 2012).

Transcutaneous methods such as transcutaneous electrical nerve stimulation and interferential current

work at lower frequencies (0.5 to 100 Hz) in the bioelectric range to alter pain signals that travel to the

brain, thereby decreasing acute and chronic pain without any discernable muscle contraction. Other

benefits may be improved circulation, lymphatic flow, swelling, and muscle function. Similarly, higher-

5

frequency electrical stimulation is used to decrease pain, improve circulation, and speed wound healing

(Doucet, 2012).

Electrical muscle stimulation, also referred to as neuromuscular electrical stimulation or e-stim, typically

delivers higher frequencies (20 – 50 Hz) to produce muscle tetany and contraction. It has two main

purposes: 1) to treat muscle atrophy during temporary extremity immobilization; and 2) to pair the

stimulation simultaneously or intermittently with a functional task in neurologically impaired individuals

(commonly referred to as functional electrical stimulation). Electrical muscle stimulation was first

applied clinically to correct foot drop in paraplegics and has become an integral part of modern

rehabilitation programs (Doucet, 2012).

Electroceutical therapy, also referred to as bioelectric nerve block, uses even higher electrical

frequencies (ranging from 1 to 20,000 Hz) to mimic the human bioelectric system. An example of this is

the Hako-Med PRO ElecDT 2000. This device employs a proprietary concept called Horizontal® Therapy

into its product, which the manufacturer claims can treat both bioelectrical and biochemical cellular

communication components in one treatment session by holding the bioelectric intensity constant while

changing the frequency. Due to safety concerns, it may only be prescribed and administered under the

supervision of a health care provider experienced in this method of treatment.

Regulation:

The U.S. Food and Drug Administration regulates neuromuscular electrical stimulators for clinical use

either through the 510(k) process or the premarket approval process. Devices required to go through

the more rigorous premarket approval process have additional issues of safety and efficacy. Several

devices have been approved for a range of indications that often overlap with other transcutaneous

methods (U.S. Food and Drug Administration, 2019a, 2019b):

Stroke rehabilitation by muscle re-education.

Relaxation of muscle spasm.

Attenuation of disuse atrophy.

Increasing local blood circulation.

Muscle re-education for other conditions.

Maintaining or increasing range of motion.

Prevention of deep vein thrombosis following surgery.

Unlike neuromuscular electrical stimulators (product codes IPF, GZI, and MKD), approved uses for

transcutaneous methods, such as interferential current therapy, typically include control of pain. As

such, these devices are regulated as transcutaneous electrical nerve stimulators (product code LIH).

Searches

AmeriHealth Caritas searched PubMed and the databases of:

6

UK National Health Services Centre for Reviews and Dissemination.

Agency for Healthcare Research and Quality.

The Centers for Medicare & Medicaid Services.

The Cochrane Library.

We conducted searches on March 5, 2019. Search terms were: “Electric Stimulation

Therapy/therapeutic use” (MeSH), “Electric Stimulation Therapy/therapy” (MeSH), and the free text

terms “neuromuscular electrical stimulation,” “functional electrical stimulation,” “functional

neuromuscular stimulation,” and “threshold electrical stimulation.”

We included:

Systematic reviews, which pool results from multiple studies to achieve larger sample sizes

and greater precision of effect estimation than in smaller primary studies. Systematic

reviews use predetermined transparent methods to minimize bias, effectively treating the

review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies.

Guidelines based on systematic reviews.

Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple

cost studies), reporting both costs and outcomes — sometimes referred to as efficiency

studies — which also rank near the top of evidence hierarchies.

Findings

The evidence from several systematic reviews, meta-analyses, and guidelines suggests electrical muscle

stimulation is safe and efficacious when used in accordance with established rehabilitation protocols

requiring supervision or in unattended settings (Fehlings, 2017; Gatewood, 2017; Ho, 2014; Lee, 2017;

Moll, 2017; National Institute for Health and Care Excellence, 2009, 2013; Prenton, 2016; Winstein,

2016). Overall, the evidence is of low quality with few randomized controlled trials, and heterogeneous

with respect to devices and treatment protocols, making it difficult to identify the optimal treatment

regimen for any one indication. Most of the literature consists of studies of adults with spinal cord injury

or stroke or after orthopedic knee surgery, and, to a lesser extent, in children with cerebral palsy.

Neuromuscular fatigue is the main limitation of electrical muscle stimulation. Its delivery can be

customized to reduce fatigue and optimize force output by adjusting the associated stimulation

parameters (e.g., frequency, amplitude, intensity, electrode placement, and pulse patterns). Conductive

garments may be used to provide pathways for electrodes and lead wires for large or hard-to-reach

areas (Doucet, 2012).

Neuromuscular electrical stimulation of any type is contraindicated in persons with cardiac pacemakers.

Other contraindications are specific to the device, although few have been described either in product

labeling or the literature. In the case of functional electrical stimulation, the manufacturer of the

Parastep 1 system lists autonomic dysreflexia, irreversible contracture, skin disease or cancer at area of

7

stimulation, severe osteoporosis, and severe scoliosis as additional contraindications (Sigmedics, 2019).

It is reasonable to extrapolate these to other functional electrical stimulation devices.

There is insufficient evidence to recommend the Hako-Med PRO ElecDT 2000 for electrical muscle

stimulation. The evidence consists of three randomized controlled trials that addressed treatment of

pain related to knee osteoarthritis or spinal fractures or degeneration (Di Sante, 2012; Zambito, 2006,

2007). While these studies found favorable results for horizontal therapy compared to interferential

modalities or placebo, evidence-based guidelines found inconclusive evidence to support

transcutaneous electrical nerve stimulation or other electrotherapy for these indications and made no

mention of horizontal/electroceutical therapy (American Association of Orthopaedic Surgeons, 2013;

Qaseem, 2017).

Neuromuscular electrical stimulation:

In an immobilized extremity, neuromuscular electrical stimulation can control edema, increase local

blood circulation, maintain muscle tone, or delay the development of disuse atrophy (Doucet, 2012). It

has been proposed as treatment for muscle atrophy in conditions such as cerebral palsy, congestive

heart failure, progressive neuromuscular diseases, chronic obstructive pulmonary disease, and upper

extremity hemiplegia. In these populations, the rationale for use is to enhance the effects of

rehabilitation or provide an alternative for patients with muscle weakness who have difficulty engaging

with traditional rehabilitation services.

There is sufficient evidence to recommend neuromuscular electrical stimulation as part of a

comprehensive rehabilitation program to attenuate muscle atrophy in immobilized limbs following a

non-neurological injury or surgery where the nerve supply to the muscle is intact (e.g., post orthopedic

surgery, casting or splinting, soft-tissue scarring) (Gatewood, 2017). For all other indications, there lacks

sufficient evidence of comparative effectiveness to recommend neuromuscular electrical stimulation as

an adjunct to, or replacement for, standard rehabilitation interventions (Dewar, 2015; Hajibandeh,

2015; Jones, 2016; Maltais, 2014; Martimbianco, 2017; McAlindon, 2014; McCaughey, 2016; Mills, 2015;

Newberry, 2017).

Functional electrical stimulation:

In the lower extremities, functional electrical (muscle) stimulation has been used to perform stationary

exercise and assist with standing and walking. For persons with upper extremity paralysis caused by

injury or disease of the central nervous system, it has been used to improve hand function and range of

motion, and correct or prevent glenohumeral subluxation in stroke. Devices used to augment stationary

exercise are considered exercise equipment and not necessarily for medical use.

There is sufficient evidence to support functional electrical stimulation for the following indications as

part of a comprehensive rehabilitation program:

8

To correct foot drop in persons with stroke or spinal cord injury when an ankle-foot orthosis

is not tolerated (Moll, 2017; National Institute for Health and Care Excellence, 2009;

Prenton, 2016).

To improve hand function and active range of motion in patients with hemiplegia due to

stroke or upper limb paralysis, and minimal volitional movement, after a trial showing

evidence of muscle contraction but inability to move the arm against resistance (Fehlings,

2017; National Institute for Health and Care Excellence, 2013; Winstein, 2016).

To correct or prevent glenohumeral subluxation in patients after stroke (Lee, 2017;

Winstein, 2016).

In spinal cord injury care, to assist in ambulation using the Parastep I system (Ho, 2014;

Sigmedics, 2019).

Policy updates:

In 2019, we added seven systematic reviews and meta-analyses that confirm previous findings for the

following indications: to attenuate muscle disuse atrophy in immobilized lower limbs after orthopedic

surgery to the lower limbs (Bistolfi, 2018; Hauger, 2018; Wylde, 2018); to restore upper limb hand and

wrist function in post-stroke hemiplegia (de Freitas, 2018; Mirkowski, 2019; Monte-Silva, 2019); to

correct foot drop (Prenton, 2018).

We consolidated CCP.1027 Electrical stimulation for oropharyngeal dysphagia into this policy and

updated the findings. The initial policy found insufficient evidence to support electrical muscle

stimulation for treating dysphagia based on systematic review findings (Chen, 2016; Scutt, 2015). A new

Cochrane review (Bath, 2018) of six low-quality randomized controlled trials (n = 312 participants) found

neuromuscular electrical stimulation was probably effective for reducing pharyngeal transit time (mean

difference -0.23, 95 percent confidence interval -0.39 to -0.08, P = .003) but did not reduce the

proportion of participants with dysphagia at end of trial (P = .22) or penetration aspiration score (P =

.24), and did not improve swallowing ability (P = .20). No InterQual® criteria (Change Healthcare LLC,

Philadelphia, Pennsylvania) addressed electrical muscle stimulation for dysphagia. No policy changes are

warranted. The Policy ID was changed from CP# 09.02.09 to CCP.1377.

References

Professional society guidelines/other:

American Association for Orthopaedic Surgeons. Treatment of osteoarthritis of the knee. Evidence-

based guideline. 2nd Edition. 2013.

https://www.aaos.org/cc_files/aaosorg/research/guidelines/treatmentofosteoarthritisofthekneeguideli

ne.pdf. Accessed March 16, 2018.

9

Fehlings MG, Tetreault LA, Aarabi B, et al. A clinical practice guideline for the management of patients

with acute spinal cord injury: Recommendations on the type and timing of rehabilitation. Global Spine

Journal. 2017;7(3 Suppl):231S-238S. Doi: 10.1177/2192568217701910.

Maltais F, Decramer M, Casaburi R, et al. An official American Thoracic Society/European Respiratory

Society statement: update on limb muscle dysfunction in chronic obstructive pulmonary disease. Am J

Respir Crit Care Med. 2014;189(9):e15-62. Doi: 10.1164/rccm.201402-0373ST.

McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of

knee osteoarthritis. Osteoarthritis Cartilage. 2014;22(3):363-388. Doi: 10.1016/j.joca.2014.01.003.

National Institute for Health and Care Excellence. Functional electrical stimulation for drop foot of

central neurological origin. Interventional procedures guidance [IPG278].

https://www.nice.org.uk/guidance/ipg278/chapter/1-Guidance. Published January 2009. Accessed

March 5, 2019.

National Institute for Health and Care Excellence. Stroke rehabilitation in adults. Clinical guideline

[CG162]. https://www.nice.org.uk/guidance/CG162. Published June 2013. Accessed March 5, 2019.

Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic

low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med.

2017;166(7):514-530. Doi: 10.7326/m16-2367.

Sigmedics. The Parastep 1® system. Indications, contraindications, warnings, precautions and adverse

effects. http://www.sigmedics.com/sites/default/files/field/files/users_manual_pg_1-3.pdf. Accessed

March 5, 2019.

U.S. Food and Drug Administration. 510(k) Premarket Notification database searched using product

codes IPF, GZI, and LIH. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm. Accessed

March 5, 2019.(a)

U.S. Food and Drug Administration. Premarket approval (PMA) database searched using product code

MKD. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pma.cfm. Accessed March 5,

2019.(b)

Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: A guideline

for healthcare professionals from the American Heart Association/American Stroke Association. Stroke.

2016;47(6):e98-e169. Doi: 10.1161/str.0000000000000098.

Peer-reviewed references:

10

Dewar R, Love S, Johnston LM. Exercise interventions improve postural control in children with cerebral

palsy: a systematic review. Dev Med Child Neurol. 2015;57(6):504-520. Doi: 10.1111/dmcn.12660.

Di Sante L, Paoloni M, Dimaggio M, et al. Ultrasound-guided aspiration and corticosteroid injection

compared to horizontal therapy for treatment of knee osteoarthritis complicated with Baker's cyst: a

randomized, controlled trial. Eur J Phys Rehabil Med. 2012;48(4):561-567.

https://www.minervamedica.it/en/journals/europa-

medicophysica/article.php?cod=R33Y2012N04A0561. Accessed March 5, 2019.

Doucet BM, Lam A, Griffin L. Neuromuscular electrical stimulation for skeletal muscle function. Yale J

Biol Med. 2012;85(2):201-215. National Center for Biotechnology Information.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3375668/pdf/yjbm_85_2_201.pdf. Accessed March 6,

2018.

Gatewood CT, Tran AA, Dragoo JL. The efficacy of post-operative devices following knee arthroscopic

surgery: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2017;25(2):501-516. Doi:

10.1007/s00167-016-4326-4.

Hajibandeh S, Hajibandeh S, Antoniou GA, Scurr JR, Torella F. Neuromuscular electrical stimulation for

thromboprophylaxis: A systematic review. Phlebology. 2015;30(9):589-602. Doi:

10.1177/0268355514567731.

Hako-Med Holdings, Inc. Products Page. PRO ElecDT® 2000 WITH VasoPulse®2000.

http://www.electromedicine.com/. Accessed March 15, 2018

Ho CH, Triolo RJ, Elias AL, et al. Functional electrical stimulation and spinal cord injury. Phys Med Rehabil

Clin N Am. 2014;25(3):631-654, ix. Doi: 10.1016/j.pmr.2014.05.001.

Jones S, Man WD, Gao W, et al. Neuromuscular electrical stimulation for muscle weakness in adults with

advanced disease. Cochrane Database Syst Rev. 2016;10:Cd009419. Doi:

10.1002/14651858.CD009419.pub3.

Lee JH, Baker LL, Johnson RE, Tilson JK. Effectiveness of neuromuscular electrical stimulation for

management of shoulder subluxation post-stroke: a systematic review with meta-analysis. Clin Rehabil.

2017;31(11):1431-1444. Doi: 10.1177/0269215517700696.

Martimbianco ALC, Torloni MR, Andriolo BN, Porfirio GJ, Riera R. Neuromuscular electrical stimulation

(NMES) for patellofemoral pain syndrome. Cochrane Database Syst Rev. 2017;12:Cd011289. Doi:

10.1002/14651858.CD011289.pub2.

11

McCaughey EJ, Borotkanics RJ, Gollee H, Folz RJ, McLachlan AJ. Abdominal functional electrical

stimulation to improve respiratory function after spinal cord injury: a systematic review and meta-

analysis. Spinal Cord. 2016;54(9):628-639. Doi: 10.1038/sc.2016.31.

Mills PB, Fung CK, Travlos A, Krassioukov A. Nonpharmacologic management of orthostatic hypotension:

a systematic review. Arch Phys Med Rehabil. 2015;96(2):366-375.e366. Doi:

10.1016/j.apmr.2014.09.028.

Moll I, Vles JSH, Soudant D, et al. Functional electrical stimulation of the ankle dorsiflexors during

walking in spastic cerebral palsy: A systematic review. Dev Med Child Neurol. 2017;59(12):1230-1236.

Doi: 10.1111/dmcn.13501.

Newberry SJ, FitzGerald J, SooHoo NF, et al. Treatment of osteoarthritis of the knee: An update review.

Comparative Effectiveness Review No. 190. (Prepared by the RAND Southern California Evidence-based

Practice Center under Contract No. 290-2015-00010-I.) AHRQ Publication No.17-EHC011-EF. Rockville,

MD. Agency for Healthcare Research and Quality website.

www.effectivehealthcare.ahrq.gov/reports/final.cfm. Published May 2017. Accessed March 5, 2019.

Prenton S, Hollands KL, Kenney LP. Functional electrical stimulation versus ankle foot orthoses for foot-

drop: A meta-analysis of orthotic effects. J Rehabil Med. 2016;48(8):646-656. Doi: 10.2340/16501977-

2136.

Zambito A, Bianchini D, Gatti D, et al. Interferential and horizontal therapies in chronic low back pain

due to multiple vertebral fractures: a randomized, double blind, clinical study. Osteoporos Int.

2007;18(11):1541-1545. Doi: 10.1007/s00198-007-0391-3.

Zambito A, Bianchini D, Gatti D, et al. Interferential and horizontal therapies in chronic low back pain: a

randomized, double blind, clinical study. Clin Exp Rheumatol. 2006;24(5):534-539.

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwjp3c3r1-

vgAhVRh-

AKHSTqAvAQFjAAegQIBxAC&url=https%3A%2F%2Fwww.clinexprheumatol.org%2Farticle.asp%3Fa%3D2

957&usg=AOvVaw0cmEjpnWcvgDDM337Er5Rw. Accessed March 16, 2018.

Centers for Medicare & Medicaid Services National Coverage Determinations:

160.12 Neuromuscular Electrical Stimulation (NMES).

160.13 Supplies Used in the Delivery of Transcutaneous Electrical Nerve Stimulation (TENS) and

Neuromuscular Electrical Stimulation (NMES).

Decision Memo for Neuromuscular Electrical Stimulation (NMES) for Spinal Cord Injury (CAG-00153R).

Local Coverage Determinations:

12

No Local Coverage Determinations identified as of the writing of this policy.

Commonly submitted codes

Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is

not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and

bill accordingly.

CPT Code Description Comments

Not Applicable

ICD-10 Code Description Comments

M21.371-

M21.379 Foot drop

M62.52-

M62.539 Muscle wasting and atrophy, arm/forearm

M62.551-

M62.569 Muscle wasting and atrophy, thigh/lower leg

S14.10A-

S14.109S Other and unspecified injuries of cervical spinal cord

S24.101A-

S24.109S Other and unspecified injuries of thoracic spinal cord

S34.101A-

S34.109S Other and unspecified injuries of lumbar spinal cord

S43.081A-

S43.083S Subluxation of shoulder joint

HCPCS

Level II Code Description Comments

E0731 Form-fitting conductive garment for delivery of TENS or NMES (with conductive

fibers separated from the patient's skin by layers of fabric)

E0745 Neuromuscular stimulator, electronic shock unit

E0764

Functional neuromuscular stimulation, transcutaneous stimulation of sequential

muscle groups of ambulation with computer control, used for walking by spinal

cord injured, entire system, after completion of training program

E0770 Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle

groups, any type, complete system, not otherwise specified